Provider Demographics
NPI:1255688537
Name:CHANGING TIDES THERAPY LLC
Entity Type:Organization
Organization Name:CHANGING TIDES THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERARDI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:508-221-3259
Mailing Address - Street 1:PO BOX 3316
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02584-3316
Mailing Address - Country:US
Mailing Address - Phone:508-221-3259
Mailing Address - Fax:
Practice Address - Street 1:10 WESTMOOR LN
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2100
Practice Address - Country:US
Practice Address - Phone:508-221-3259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty